Division Director Payer Strategy

Location

Englewood, CO | United States

Job description

Overview

CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.

Job Summary / Purpose

The Director,  Payer Strategy and Relationships (PSR), is responsible for managed care policies, goals and objectives related to contract language and reimbursement, negotiation strategy, and payer relationships.    The Director collects and communicates Division-level insight and strategic knowledge to/from the PSR National Payer teams, the PSR Growth & Innovation team, and other key departments across the enterprise. This position is essential to CommonSpirit Health’s financial performance, and has significant impact on the long-term strategic trajectory of the organization. This position secures optimal fee for service and value-based reimbursement, protects the interests of the owned and/or affiliated hospitals/ancillaries/professional provider entities in contract negotiations, and strengthens CommonSpirit Health’s relationships with payers .

Essential Key Job Responsibilitie

1. Participates in the development of Division strategy, relationships, and contracts with local and national payers to further drive a clear and effective negotiation strategy, reimbursement structure, contract renewal planning process, and contract implementation. Budgeted and forecasted performance and growth requirements as set forth by national and Division senior leaders are integral to these processes.
2. Gathers information and guidance from Division PSR VP, ministry leaders, internal stakeholders, and financial analysis relative to the strategic, operational, financial needs and expectations of the Division related to the National Payers; proactively communicates with the PSR National Payer teams. 
3. Establishes, builds, and maintains positive, strategic interactions and relationships with payers, employers, providers, and leaders across the ministry. Maintains relationships with National Payer contacts with offices in the Division.  This includes maintaining appropriate Center of Excellence (COE) Designations.
4. In collaboration with Division Leadership and other PS&R Leadership, develops and executes communication plans and Payer Negotiation Outlines related to payer relationships, negotiations, organizational contractual obligations, and developments in the managed care marketplace including Fee For Service and Value-Based Agreements in support of CommonSpirit Health’s Healthier Communities strategy.
5. Makes independent decisions and/or exercises judgment based upon appropriate information and objectives.  Comprehends and maintains highly detailed information.  Accepts and carries out responsibility for direction, control, and planning. 
6. Stays current with emerging payer trends, new reimbursement methodologies, state specific regulatory issues, plan benefits, payer activity, products and delivery channels including health insurance exchanges, market competition, etc.
7. Supports the strategic objectives of CommonSpirit Health’s IDNs, population health, and care management initiatives through directly engaging local payers and employer customers, including CSH employee health benefits.
8. Participates in and contributes to CommonSpirit Health’s PSR knowledge base through sharing best practices, developing contract performance goals, key metrics, new analytical tools, network development, reimbursement and language guidelines, revenue realization, and other applicable work streams.
9. Participates in the dispute resolution and denials processes with local payers if the materiality exceeds $1M.  Participates in joint operating committees and denial committees for Division.
10. Leads and organizes sub-projects necessary to support local and national payer negotiations and growth

• Bachelor’s Degree – equivalent education and experience in payer strategy, managed care or provider network senior level role may be considered in lieu of degree
• Minimum of five (5) years of experience in healthcare or managed care industry
• Minimum of four (4) years of leadership experience
• Working knowledge of  provider and payer industry 
• Strength in assessing problems and implementing solutions
• Significant knowledge of contractual, administrative, health insurance and operational issues related to managed care organizations, physician groups, hospitals and health insurance benefit plan designs
• Proven and extensive technical skills, negotiation skills, contract preparation and implementation, financial analysis and rate proposal development, and in-depth knowledge of various reimbursement methodologies for both fee for service and value-based contracts.
• Demonstrated ability to set and maintain multiple priorities in an environment with shifting priorities, while providing accurate deliverables in a timely fashion.
• Strength in self-motivation and ability to assume ownership of assignments and projects. Driven to succeed.   
• Strong interpersonal, verbal, and writing skills in dealing with payers, guests and team members.

Job tags

Salary